Connected ageing

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December 17, 2014 |
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Can technology fill the care gap?

With the number of Europeans aged over 60 set to double in the next 50 years, and the number of over-80s to triple, meeting the future care needs (and health costs) of ageing populations is critical. How can telecare, telehealth, robots and ICT help Europe’s senior citizens?

Meet Annabelle. She’s a retired lawyer and lives in a large city and has been exceptionally healthy almost all her life. In the last year, however, Annabelle has gone through intensive rehabilitation after a femoral neck fracture. She is still, to a certain degree, physically impaired and has become more anxious after the incident. Annabelle lives alone. Though she has used a computer for many years in her working life, she is not interested in technology or other digital tools. Annabelle finds new software or gadgets ‘demanding’ and she is sceptical about the safety of her personal information when it is processed by the different systems.

From the PACITA scenarios

Annabelle is just one of many European senior citizens who will need care in the near future. Projections show that she could live well into her nineties, alongside many of her peers. Annabelle could be diagnosed with a chronic illness, or with dementia. She is a widow and her children live elsewhere. Who is going to take care of Annabelle?

‘It is not possible to introduce new technology and not adapt the systems surrounding it. We need to look at governance, procedures, processes and patient involvement.’

Digital empowerment

The EU sees technology as a key solution. In the Digital Agenda for Europe, it expands on ICT’s capabilities for supporting ageing citizens, revolutionizing healthcare and providing better public service. Mrs Neelie Kroes, Vice-President of the European Commission and responsible for the Digital Agenda recently stated:

“Let us work together to capture the massive opportunities of new technologies – for our people to stay active and independent, empowered and in control. In turn, helping our healthcare systems and our economy. You are all aware of the facts: they are inevitable. People are getting older and more demanding. But getting older shouldn’t mean losing your dignity and independence. If facing a possible health problem, people expect answers about what they themselves can do about it. In a digital age, it should not be impossible to meet that expectation.”

Technology can play an important role in many areas of the care sector, explains Hilde Lovett, project manager at the Norwegian Board of Technology: “It can execute tasks, such as domestic chores, assist with medication or personal hygiene, and remind us of appointments and social occasions. It can increase mobility and active participation in society and help maintain and build social relations.” But we should also be aware that new technology could bring negative and undesired consequences. If visits by healthcare personnel are replaced by technology and remote communication, the risk of loneliness and isolation could be high.

That was one of the fears that came up at the PACITA workshops that took place in ten European countries during the spring of 2014. The workshops engaged stakeholders in discussion with the aim of producing policy recommendations for national and European policymakers on the topic of care for the ageing and technology.

European stakeholder initiativesIn the UK, the Technology Enabled Care Services (TECS) programme, announced in September 2014, aims to create the right commissioning environment to support and encourage the innovative use of technology to improve health outcomes, empower patients, and deliver more cost-effective services. The re-focus from its predecessor, the 3millionlives project, is a result of demands from health and social care professionals for more practical support in evaluating technology-enabled care services. An online tool is to follow later this year. The TECS Stakeholder Forum’s collective views and proposals on how to address the barriers to wider adoption form the basis of the TECS Improvement Plan 2014-17.The EU’s Innovation Partnership on Active and Healthy Ageing has an overall goal of increasing the average healthy lifespan by two years by 2020. They also see great market potential in healthcare technologies, and see stakeholder involvement as a chance to “boosting and improving the competitiveness of markets for innovative products and services, responding to the ageing challenge at both EU and the global level.”

Policymaking for the ageing in Europe

George (79) has dementia. He lives in his own house in a small town but depends on professional help and support in order to live on his own. George was a long-distance bus driver and his retirement pension is relatively modest. He’s in good physical condition and enjoys moving around inside and outdoors. But since dementia causes disorientation, George needs help finding the way. His occasional amnesia makes him dependent on others for managing his personal finances in order to be able to live alone. George enjoys different social activities – but he does not always remember how to take the initiative.

From the PACITA scenarios

‘Even though many senior citizens will struggle with health conditions, many will live long and healthy lives. These seniors could contribute in many ways.’

Although the EU looks to technology to solve the challenges ahead, there are several barriers that need to be overcome if technology is to contribute to the care sector in a positive way. Stakeholders at the PACITA workshops identified some of these barriers and discussed potential solutions. Since developments in technology move a lot faster than policies, it is important for policymakers to address these challenges as soon as possible.

Health not wealth: managing ageing earlier

Many of the stakeholders involved in the PACITA project emphasized the need for a governmental strategy to serve as the starting point. That strategy should aim at tackling the challenges in the healthcare system but also support societal values and encourage social contact for senior citizens. Stakeholders argued that a governmental health service has to be the starting point, to ensure that everyone receives basic care. On top of this, different approaches to implementing technology and new ways of organizing care services should be considered. Without such a fundamental strategy, stakeholders feared the development of a societal divide: seniors with wealth and who were technologically competent would be far better off than others.

Privacy and data protection are two issues that were considered very important by stakeholders. If the care sector were to start relying on self-monitoring, home alarm systems and GPS tracking, for example, there need to be new regulations and routines that can handle the growing amount of data which will be generated. Who should be allowed access to these data? Should relatives be able to monitor their loved ones any time they want?

Another recurring theme at the PACITA workshop was the need to take responsibility for our own ageing process and to a greater degree than before. We need to start earlier and talk with relatives and friends about how we want to live as seniors. If the greatest wish is to live at home as long as possible, adjustments that will make this possible need to be made early on. What types of technology could make your everyday life easier? Many people (but not everyone) will be diagnosed with dementia, so there are privacy and ethical implications that should be discussed with your relatives or doctor. How would you feel about your children being able to track your movements with a GPS? Would you be more comfortable moving to a care facility where there are personnel who can watch out for you?

The potential of innovation

To what degree different countries and regions have implemented technology in the care sector differs widely. But there is clearly an emerging trend of using technology – and the industry is flourishing.

César Rubio works with FENIN, the Spanish Federation of Healthcare Technologies, an organization that acts as a link between the industry and public administration in order to improve the health quality of Spanish citizens. He states that although technology is a part of the future, there are other changes that also must be acknowledged. It is not only technology that is changing, argues Rubio, but also the way we deliver healthcare services.

Hilde Lovett agrees with this: “It is unfortunate if the technology is implemented without looking at the bigger picture. How to work smarter, be more efficient and at the same time deliver better services will be a challenge.” Although there is a need to make care services more efficient, the stakeholders engaged in the PACITA project argued that the focus need to be on creating better care, not just on the economic benefits.

There are high hopes for the business potential of technology for care. The European Innovation partnership on Active and Healthy Ageing is one of the initiatives that the Commission has introduced to enhance competitiveness in addressing social innovation. The Commission has financed numerous research and development projects with the aim of building knowledge capacity and environments for innovation in the field of care technology. As stated on the website of the Innovation partnership “…the field of active and healthy ageing has potential for Europe to be in front when it comes to research and innovation.”

Hilde Lovett sees the Commission’s effort as positive. One of the main feedbacks from the workshops in the PACITA project is the need for arenas where knowledge exchange can happen between different types of stakeholders. In order to create solutions and strategies that will work when implemented, they need to be developed in a cooperative manner, taking into account the arguments from policymakers, the industry, employees in the care sector and the end users themselves.

César Rubio looks at the future changes from the industry’s side. We need to change the whole healthcare system, he argues. It is not possible to introduce new technology and not adapt the systems surrounding it. We need to look at governance, procedures, processes and patient involvement. Hospitals today are built around a ‘one size fits all’ approach. For newer concepts of care, flexibility is a must, in order to achieve the necessary changes.

Rubio also sees commitment as an important issue: policymakers need to create a platform where relevant stakeholders can meet and discuss different approaches. But there will also be a need for a clear strategy and decision makers need to show the industry and other stakeholders that they are willing to carry out changes according to the strategy, he argues.

‘Life expectancy will continue to increase, yet unhealthy life years make up around 20% of a person’s life.’

The need for flexibility was emphasized during the scenario workshops. It became evident that cultural and social traditions in Europe are quite different. It will therefore be important to make systems that have room for national or regional adaptations, so that the changes in the healthcare system have the best possible chance of succeeding.

Cost-effective?

For governments and policy makers designing strategies to deal with the ageing demographic and its impact on care budgets, determining the cost-effectiveness of new technologies is a critical consideration. Recent research from the the Parliamentary Office of Science and Technology in the UK suggests that not only will telehealth and telecare need to be implemented on a ‘large scale’ if it is to be cost-effective but coordination between a wide range of care sectors will also be required for success.

In assessing existing telecare and telehealth initiatives in the UK: “The largest of these showed a potential reduction in deaths among patients, but found that telehealth and telecare did not reduce use of social or healthcare.” Using technology brings risks and acceptance issues. There are many thousands of ‘health’ apps for mobile phones and while those providing diagnostic or dosage information could be considered ‘medical’ devices and therefore covered under the EU Medical Devices Directive, are they being monitored effectively? Interactive devices that self-monitor and manage conditions such as diabetes are predicted as one of the technology growth areas according to the report, also sensors – organic electronics – and the use of neural networks and interpretive systems.

Cost-effectiveness is only one measure of success. Studies that look at patient satisfaction and quality of life following the introduction of technology get mixed results, the report stated. Might a patient with a chronic condition reject a device that continually reminds them of their illness?

Disentangling the effect of technologies within the context of care, the role private companies have to play, even whether those who commission services are in a position to judge whether they are being delivered to high standards, are all important considerations. The conclusion in the UK was cautious: “However the technology develops, it is unlikely to deliver a silver bullet. Successful implementation of new technology will depend on the coordinated efforts of patients, clinicians and workers throughout the health and social care sectors.”

In theory, technologies should free up time and space for more personal care. There have been a number of promising applications.

Innovative ageingTelemedicine, eHealth, ambient assisted living (AAL) and telecare are some of the many concepts describing the use of technology in care services. There is a lot of innovative effort in these areas.. A technology overview made by the PACITA project shows the European care sector has implemented a wide array of technologies ranging from alarm systems, fall sensors and detectors, to smartphone apps and self-monitoring equipment connected to the Internet. Employees in the care sector are also equipped with communication and administrative devices.

Robocare

Robots come in a variety of shapes, sizes and functionality. In Denmark, most municipalities have experimented with robotic vacuum cleaners in nursing homes – an evaluation made by Copenhagen Business School in 2009 estimated that implementing these robots on a regular basis could save approximately one thousand cleaning jobs. A robot vacuum cleaner might not seem like a huge change; using technology to do mundane tasks like this has not received much criticism. Low-tech changes to lighting and flooring can also make a real contribution to creating more dementia-friendly living environments.

A robot that has caused far more debate is Paro – a robotic seal intended for social contact and for providing emotional stimulation of patients with dementia. “Stress and anxiety in patients with dementia can be hard to treat and demands a lot of attention from care personnel”, explains Hilde Lovett. “One can use sedatives of course, but what if there was another way that does not include heavy medication?”

Paro was developed in Japan but has been tested and implemented in several European countries since 2003, including Denmark, Germany and the UK. Marketed as the ‘World’s most therapeutic robot’, Paro reacts to touch and sound and responds with small movements and noises. Some have expressed scepticism about the ethics in this, because they feel that the patients are deceived into thinking they are interacting with a living creature, but there are also many arguments in favour of its use. Paro has been well received in many pilots, Lovett explains: “The robot gives the patients a sense of being a care-giver and the response the seniors get from the seal seems to
calm them and stabilize their mood without having to use medication.”

doctor@home

The number of seniors with chronic diseases will increase in the coming years. Seeing that the need for monitoring and frequent check-ups by medical personnel will exponentially increase, several technological solutions have been developed to reduce the pressure on the health services and put more of the care responsibility on patients themselves.

‘However the technology develops, it is unlikely to deliver a silver bullet. Successful implementation of new technology will depend on the co-ordinated efforts of patients, clinicians and workers throughout the health and social care sectors.’

One of the most common chronic conditions is chronic obstructive pulmonary disease (COPD). The World Health Organization (WHO) predicts that COPD will become the third leading cause of death worldwide by 2030. A technology that has been developed for this condition is a COPD-kit, which allows patients to monitor their condition at home. They measure their vital signs, and answer questions related to their feeling of well being. Many of these telehealth kits also include options for communicating with medical personnel via video or email if a patient needs advice.

Unwelcome illness

Living with a chronic condition can be psychologically difficult. If patients have a bad day, they might seek reassurance from an appointment with their doctor. If they leave it until it is too late, a stressful hospital admission becomes necessary. Daily monitoring can create a continuous overview of a patient’s condition providing important information for medical personnel and can help identify triggers that worsen or improve well being. It could empower patients, giving them a greater feeling of being in control of their own condition. Although being a constant reminder of an unwelcome illness, the patients seem to appreciate controlling it in a comfortable, familiar environment, rather thanhaving to make daily trips to a hospital.

A technology overview made by the PACITA project shows that alarm systems are among the most widespread use of technology in European homes. But we are just at the starting point of really exploring this field. Innovation and implementation projects, developing and testing technology that seniors could use at home, are taking place all over Europe.

Visiting Alma

In Oslo, Norway, ‘Alma’s House’ is a fully furnished apartment which functions as a testbed showroom of assistive technology (AT) for people with dementia and cognitive disorders that can be implemented in the home. These include safetyoriented aids, like fall sensors or smoke and fire detectors, and technology for social contact and communication. These include easy-to-use telephones, calendars and watches with speech implementation. Sensors detect if a resident leaves the house in the middle of the night with tracking devices that can locate residents who are lost. The aim of the showroom is to have a place where decision-makers, seniors and relatives, healthcare personnel and other stakeholders can visit, and see and try different technologies.

Sigrid Aketun works as an advisor at the City of Oslo Resource Centre for Geriatric Care and has been involved with the development of Alma’s house. “The feedback has been great”, she reports. “Since the opening in 2012, we have had approximately 3,000 visitors. They range from decision makers and other actors who plan and organize care services, but we also see groups from senior centres and organizations. The project has also gotten international attention and representatives from five other countries have visited Alma’s house.”

Providing an informal arena where different stakeholders can visit is one of the key successes of Alma’s House. The perceived conflict between ‘cold’ technology and ‘warm’ hands when it comes to care might be overcome with initiatives like this; it’s not a question of either/or. According to Aketun, “Our advantage has been that we have placed the technology in a physical environment which is adapted to the users. It shows how the technology can fit into the homes of seniors and help with everyday challenges without the technology ‘taking over’ the home completely.”

A shared responsibility

Are there, apart from sedatives, other ways to reduce stress in elderly patients?

Kevin (72) and Laura (68) live with their son and his family. Kevin is in poor health and does not go out very much to meet other people, but he is an active user of social media. He is part of a municipal online community for senior citizens where he helps others to choose and use new technology. As a retired engineer he likes to share his technological expertise and has a key role in the community.

Laura is still very healthy and uses her daily trip to the grocery store to keep in shape. On her way to the grocery shop, she checks in on three of her neighbours who are less mobile than herself. After her visits, she clicks ‘ok’ on a smartphone app that sends a message to the local care services. Laura is happy to help the neighbours and also appreciates the free hour of housekeeping she receives in return for looking after other seniors.

From the PACITA scenarios

At several of the PACITA workshops it was stressed how important it is to look at senior citizens as a valuable asset to society and not simply as a burden on the healthcare system. Almost all stakeholders had positive reactions towards an imagined scenario which emphasizes a strong volunteer effort.

“Even though many senior citizens will struggle with health conditions, many will live long and healthy lives”, explains project manager Hilde Lovett. “These seniors could contribute in many ways, whether it is grocery shopping for other seniors, organizing social events or staffing the cafeteria at the care centre. It should be possible, and encouraged, to engage volunteers, both seniors and others, in care work in the future”, Lovett argues.

Stakeholders from all kinds of backgrounds agree that technology can be a solution for many of our challenges. But even more importantly, they highlight that the need to uphold societal values like privacy, dignity and a social network will increase in importance as technology makes its way into the care sector and our homes.

Care services for the elderly will probably look very different in the future. But we can all be part of forming policy for those services, whether we work in the care sector, develop technology, volunteer in our local community – or simply because we all grow older. It is important that national and European policymakers involve a broad spectrum of stakeholders to make the best possible future for Europe’s seniors, particularly in the light of the demographic and economic challenges Europe is facing. Seniors need help and support and although technology can solve some of these challenges, there needs to be a cooperative effort among many stakeholders to create technology and care services that will work together.

Ageing in 2025: What choices will we have?

During the spring and summer of 2014, the PACITA project organized scenario workshops in ten European countries, engaging more than 330 stakeholders in discussion about care, technology and the future of ageing. The aim has been to identify policy options for European policy makers, and make recommendations on how we can deal with the dilemmas that will occur when technology is introduced in the care sector. In addition to the workshops, the PACITA project has studied the current use of technology in different European countries, and how far decision-makers have come in making explicit policies on the topic.

Why engage stakeholders?

Those that are affected, positively or negatively by research, technological development and policy decisions are not always consulted, even though they have a stake in the issue. Stakeholder involvement is one way of making decisions more robust and socially acceptable and the variety of voices will make the discussions open to different kinds of knowledge, perspectives and dilemmas. PACITA stakeholders included those from backgrounds such as local decision-making, the care sectors, IT, volunteers and representatives from senior organizations. They discussed and identified challenges and possibilities related to the implementation of technology in care.

Future scenarios

To create a common starting point for the stakeholders, the PACITA partners developed a set of future-oriented scenarios that served as a starting point for the discussions. The scenarios described different ways of organizing and funding care services, and different ways of using technology to increase the quality of healthcare for senior citizens. The scenarios also included stories presenting fictional characters, describing the way their everyday life is affected by the choices politicians make. Scenarios are a great tool for facilitating forward-looking discussions and using fictional stories forces participants to consider different ways of organizing healthcare services, by giving direct feedback on the scenarios. The fictional characters can be used to show ethical and social dilemmas that seniors might experience in their everyday life, and how different ways of implementing technology can create different dilemmas.

Ethical issues

Could care technologies be experienced as intrusive or unpleasant surveillance? How is privacy balanced against feeling secure? Will using technologies result in senior citizens feeling more or less isolated in their communities?

WHO publish data on many aspects of global ageing. A new website, Age-friendly World, launched in October 2014, aims to highlight initiatives in cities and communities that make life easier and more enjoyable for older people.

A 50 sq meter flat, opened in 2012, which is a dementiafriendly environment demonstrating assistive technology (AT) to support people with cognitive impairments and dementia, and which also services as a knowledge service on AT.

PACITA has put into practice cross-European stakeholder involvement into debating ageing and provided both national and EU level policy makers with substantial input for meeting the societal and technological challenges and opportunities of an ageing population. The workshops took place during the spring and summer of 2014, and the policy advice will be presented to European policy-makers in January 2015.

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volTA magazine

volTA was a magazine on Science, Technology and Society in Europe, initiative of fifteen technology assessment organisations that worked together in the European PACITA project aimed at increasing the capacity and enhancing the institutional foundation for knowledge-based policy-making on issues involving science, technology and innovation. It was published between 2011 and 2015 in 8 numbers.